NEWS

Dear Readers,

Just wanted you to know that

Scientific American posted another essay by me, entitled "How conducting therapy changes the therapist": http://www.scientificamerican.com/blog/guest-blog/
(2. 26.11)

 Also  I was very pleased that the New Yorker cited the first essay published in ScientificAmerican.com in a recent article: http://www.newyorker.com/online/blogs/books/2011/...

My File Cabinet/Myself

In recent days I have learned a lot about identity.   Mine.

As we unpack our belongings: furniture, clothes, files, books, knick knacks, family photos, art,  in our new home,  many months and miles from our old home, I have experienced both the joy of reunion with  my “stuff” and the profound grief over “stuff”  gone forever.

Some of our “stuff” I haven’t seen for 3 or 4 months, some, almost a year.  As we put our house up for sale we were required by various “stagers,” consultants to the real estate industry,  to pack up beloved books,  family pictures,  and even art pieces that told too much about who we were (“too ethnic”).  Though I thought this was highly unscientific advice and was incensed by the implied criticism,  I acquiesced.

My house started to feel like an alien space.  It looked more like a “model home” than my

slightly cluttered, but very personal and, I thought, warm and homey abode. 

Due to a sluggish housing market and some bad luck,  it took many more months to sell our house and move into our new digs here in Maryland. 

The worst was the books,  followed closely by family pictures.  Both tell the story of our lives. I don’t see collecting books as a vanity project but rather a chronicle of where we have been with our intellectual passions our not so intellectual passions and indulgences, our journeys both geographic and spiritual.  Some books go back to college and graduate school.  The pictures and photo albums… well we all understand about the pictures.

What really threw me was my reaction to not having a place to unpack my files,  old patient files,  courses constructed and taught over the years, material from particularly treasured courses I took as a student,  research for academic articles long since published,  ideas for books not read,  projects never launched.

I had already wrenched myself away from boxes and boxes of this stuff.  This was the distillation  of all that torturous weeding process.

My crummy metal filing cabinets were sacrificed on the altar of expediency and the knowledge that new housing would be substantially smaller.   After all we were downsizing. 

I was really bushwhacked by how horribly upset I was when there was no cabinet to hold this aspect of my identity.   Where were my ideas, my life’s work,  going to live if not in those battered, garage-sale-quality file cabinets?  What would happen to them?   What would I do?   Who will I be?

This may all sound crazy.  I guess it is a bit,  but  I really think this aspect of my work life

was and is much more central to my identity than I realized.  My file cabinet and its contents  contribute to what makes me feel whole, integrated, and worthy.  Even if I never look at another piece of paper in those files their presence affirms me in a way that I really need.  Still.

I think its worth thinking about what there is in our lives that fulfills this role.  Sure there are our core people that play this role, spouse, children, grandchildren, extended family, good friends. And then there is art in all of its expressions that fulfills this function.  Even pets. 

What is it for you?

Start Where the Client Is At: My Client/Myself

“Start where the client is at.”

Believe it or not that was the defining sentence in my clinical courses in social work school 4 decades ago (yikes!).   It can always be counted on to elicit a chuckle in a contemporary who attended social work school around that time as well.  We all remember this.

As ungrammatical a sentence as that might appear to be—and maybe even impenetrable to the un-initiated, it turns out to summarize a great deal of clinical wisdom, wisdom that has stood the test of time.

What does it mean to start where the client is at?  It means that at least initially the clinician must eschew judgments, must listen carefully to discern what the client is feeling and thinking and not to step either too far away, or move too quickly ahead to where you think the client needs to be "at."

In reviewing my own long career as a clinician I am very aware of how hard this is, and always was, to implement, and how often I failed to do so.  If anything this got harder as I gained experience and thought I knew where the client was going.  I often was too far ahead, not putting enough effort into being in sync with people.

I sit down to write this now,  not because I need to discuss basic clinical social work principles,  but because I have just realized that this principle underlies a certain kind of mindfulness meditation training that I am pursuing with myself.  And in general, I think it is a wholesome practice for all of us

Here in the DC area I have the very good fortune to be attending weekly meditation sessions and talks with the internationally regarded insight meditation teacher, Tara Brach (www.tarabrach.com).  Tara has written a book Radical Acceptance,  and she teaches “radical acceptance.”  By radical acceptance Tara means we must accept where we are at, in order to even begin mindful practice.  Mindful practice is not just about the formal meditation practice,  but it extends to being mindful of other activities,  paying attention to whatever you are doing: cleaning the bathroom,  eating mindfully, taking care of children mindfully, all manner of daily life.  And this extends to where we are at emotionally.

One of my mindful practices is to try to catch myself when I feel unhappy when it is not for any obvious reason.  Just stopping, allowing myself the feeling makes it easier to know where I’m "at."  Once I know where I’m "at,"  I can start the acceptance part.

So I feel yucky becomes,  "I’m really very jealous of so and so,  or angry,  or disappointed or afraid."   And those feelings are automatically judged by me.  You know the drill:  I shouldn’t be jealous, angry, afraid.  Its probably the judgement, more than anything that creates the "yucky" feeling, not being a good person because I have this feeling.  But that's how it is.  And that is where I am at right now.  Its okay.  A gentleness,  a compassionate acceptance is in order.  And then we go from there.

  

What I found, when I was able to do this, was that my body “sighed”,  there was an easing of my breathing,  a release and a relief.  Maybe I didn’t feel wonderful,  but it all passed by more quickly and was less likely to ruin my day.  And as a little time went on, my understanding of these feelings deepened.  Starting where my “inner client” was and is "at,"  allows a spaciousness and a creativity in problem solving that is otherwise not there.

So once again:  start where the client is at.  And these days,  the client is me.

 P.S.  Dear Readers, 

Come visit  me on a recent Scientific American blog: 

 http://www.scientificamerican.com/blog/post.cfm?id=psychotherapy-and-the-healing-power-2011-01-19

When The Worst Thing Is Not The Worst Thing: EMDR & Unpacking Meaning

A couple of months ago I received a request from the Mesothelioma Cancer Alliance asking me to include a link to their organization on my website (www.maybenatar.com). My contact noted that she was specifically interested in reaching out to therapists who provide EMDR therapy, as research had shown this technique particularly helpful in helping individuals deal with illness and loss.

I have not seen the research but my own experience would confirm this finding.

One has to ask how and why this is so. The diagnosis of a life threatening illness like mesothelioma is devastating. How can waving your hands in front of someone’s eyes or other forms of bilateral stimulation change that?

It turns out, devastating illness means something different to every patient, just as trauma
means something different to every “victim.” The prospect of loss of function, painful treatments, and a premature death is coded differently in each of us. And unpacking that unique meaning seems to facilitate processing. Maybe we can’t even process loss without that first step, unpacking meaning.

There are many paths to understanding meaning. Psychoanalysis utilizes free association;  relational psychotherapy uses the tool of the relationship as the main vehicle to meaning. Self psychologists focus on the state of the self; their major tool is empathy

In my, admittedly, limited experience the EMDR technique can provides a short cut to meaning.

The web of memory and meaning is an intricate, unpredictable one and EMDR can help one navigate the thicket.

EMDR is a technique that utilizes a very specific protocol that unpacks aspects of specific target symptoms and then stimulates, through the use of eye movements, taps, or alternating tones an internal process that seems to move individuals through a web of associations to the presenting images/symptoms back, back, back to some memories, earlier life experiences that may hold the key to unlocking the meaning of symptoms. This is free association on steroids.

See the following links for two short videos that demonstrate in pictures what would take me too many words to describe and describe poorly at that.

http://www.youtube.com/watch?v=gZ5MLn1Cc94

http://www.youtube.com/watch?v=bqbFIj5vwmA&NR=1

Sometimes the worst thing is not the worst thing.

One middle aged gentleman came to me when the lung cancer for which he had previously been successfully treated, returned. And it returned with a vengeance. He was at stage 4. Although he still had many treatment options and his doctors held out a great deal of hope, he was understandably devastated. He was alternately enraged and despairing. He was declining treatment, fighting with his doctors, unable to eat or sleep, alienating friends and family.

It would seem obvious that his fear of death was the primary cause of his suffering. At least that was what was obvious to me. But that is not what emerged with the EMDR treatment.

What emerged within one session was a memory of having wronged a good friend many years before, in his early 20’s. He felt enormous shame and guilt when remembering this during out EMDR session. The feelings were vivid, immediate, and intense. This one incident in which he had hurt and shamed someone else made him feel that he was a bad person.

Subsequent discussion over several sessions, revealed that some important part of him felt that he was being punished for his early cruelty. Lung cancer was the pay back.

Bringing this to light made it possible to process this event with the maturity now available to him. He found some compassion for his younger self. It was also now possible to reconsider that perhaps his misdeed had not caused his cancer. Cancer is awful. Facing death at 45 is awful. But feeling that you are a really bad person and that is why you are ill, that is worse.

Sometimes the worst thing is not the worst thing.

The False Memory Wars: A Short Primer

Do you remember the false memory wars?

Probably not,  but I do.  Its effects continue to linger in a way that troubles me. 

This was a “controversy” that consumed the field of trauma therapy throughout the 90’s

It did incredible damage to the field of trauma therapy.   Therapists and patients alike were victimized by the charges of “the false memory foundation (FMSF),” that patients who were being treated by either misguided or malicious therapists were being guided to “mis-remember” childhood

events of sexual violence perpetrated against them.  Therapists lost their licenses,  patients lost their nerve,  and the whole field of trauma treatment contracted in the face of the onslaught.

Unfortunately the media embraced wholeheartedly and uncritically the charges of the FMSF.  There was a shocking lack of balance in the coverage of this controversy.

Interestingly it took the trauma of 911 and the treatment of psychological victims of that catastrophe to bring the field back to respectability.  Trauma treatment programs proliferated after 911.  Now trauma was and is about terrorism and war,  not sexual abuse.

The phenomena that was being questioned by the FMSF was the way some individuals who in the course of therapy,  or indeed just in the course of life, would be blindsided by previously unremembered events from their childhood of savage abuse usually at the hands of trusted caretakers or other family members.  Jane Smiley, in her wonderful Novel  A Thousand Acres has a wonderful description of the phenomena of being struck by such a memory.  Jane Smiley does this so artfully that the reader is “assaulted” by the information much as the character is.

How can such a thing happen?  Being literally assaulted in living color by a previously unremembered event.

We all know how unreliable our memories can be.  I could swear that I hid my expensive jewelery  in the freezer.  Why isn’t it there??  Didn’t my oldest daughter walk at 9 months?  I distinctly remember that she did.  These might be distorted, they might be wishful thinking, or they might not.  Plenty of psychological research has establish that memory deteriorates over time.  Eyewitnesses to crime are notoriously bad witnesses. This is established science.

What isn’t so well accepted and understood is that traumatic memory is different.  Through a mechanism call “dissociation” child victims of horror, torture, abuse, betrayal find a magical way to cope.  Adaptation is well served by filing away, sequestering these memories, severing them from the mainstream of experience so as to be able to go on, grow up, continue to stay attached to important attachment figures who might also be perpetrators. By the way there is neuroscience to back up this understanding of "dissociation."

When it is safe,  sometime in adulthood these “dissociated” memories can return unbidden.  And when they return they are intact—they haven’t degraded at all.  The smell of the room, the smell of the perpetrator,  the texture of the rug,  the cracks in the ceiling, they are all there.

This is the nature of traumatic memory.  And almost always these are unwelcome events, the return of the repressed.  The adult individual doubts their veracity, disowns them,  tries to forget, hides them from the therapist.  I have never known a victim of childhood abuse who didn’t try to run as far away from these memories as they could.  Trauma therapy is a torturous enterprise because the memories are so unwelcome,  so painful, at times almost unbearable.

 It is not like my memories of where I hid my jewelry.

Which is not to say that there are not unscrupulous or poorly trained therapists who prime the pump and  solicit “false memories.”  There are also individuals who present a false narrative for some secondary gain in psychotherapy.  Those are not so difficult to spot.

There have been a few and pretty small studies that have sought corroboration for their trauma patients narrative and have found a high rate of  veracity.  But for me the acid test has always been,  is the patient getting better as you lend them your unqualified support in their attempt to remember.  If the answer is “yes”  that’s all the corroboration that I need.

EMDR: CAN WE CHANGE OUR PAST/FUTURE?

 I’ve just read a book that combines two genres: science fiction and historical fiction.  In Galileo’s Dream, Galileo  is teletransported in time and space—the time is 3020- the space: the 4 moons of Jupiter, known as the Galilean moons. 

Much of the science, fictional or not, is beyond me.  But the psychology is not   If I understand correctly the purpose of these periodic teletransportations is to manipulate the outcome of Galileo’s life.  In real life G. was tried and found guilty of heresy by the Catholic Church for, among other things,  arguing for the correctness of the Copernican view of the universe,  that the earth rotated around the sun, and not as the Biblical view had it, that the earth was the center of the universe. 

The bad guys on Jupiter want G. to be burned at the stake.  They think this would mark the end of religion and clear the way for the ascendancy of science.  But not everyone agrees.  The good guys attempt to teach G. about his life so that he can maybe even avoid the heresy charges altogether.

What caught my eye was the third millennial version of a psychotherapist or even psychoanalyst,  a mnemosyne.   In Greek mythology, Mnemosyne is the Goddess of memory and the mother of the Muses.  With the help of a helmet-like device the Mnemosyne accesses nodal points in the brain where intense emotional memories are filed.  The  subject “remembers” in the deepest way.

If the,  poorly remembered past could be vividly recalled,  the theory goes,  a person will be changed and their future will be changed, not just their current “symptoms” but their future.  In the context of the book  G. held a better chance of surviving what was in store for him at the hands of the Catholic church, if  he knew himself better.  What gets changed is not the past, but one’s experience of the past and thus the future..

One of many things that caught my attention was that the technology described in this imagined Jovian future already exists.  Its called EMDR (eye movement, desensitization, reprocessing).    The modern mnemosyne (read psychotherapist) uses the protocols of EMDR to access connections between the presenting problems and the past.

In EMDR one stimulates alternately the two hemisphere of the brain by way of sound,  eye movement, tapping, or some such.  Very little special equipment is necessary, maybe ear phones for sound, or a light bar with which the subject follows lights without head movement.  This process seems to faciliatate both relaxation and a kind of free association,  so one starts with a target image and quickly begins to link to other images, that are cognitively if unconsciously connected to the original target image and symptom.  Typically what comes up in a session is an early memory that has set the individual up for the difficulties they are now experiencing.  These image and the memories that arise are “re-processed” and the anxiety, the symptoms diminish.  They really do.

The EMDR protocol  is typically part of an overall treatment process, and my description here is barely adequate.  For more information see   http://www.emdr.com/briefdes.htm 

My point here, is that with the aid of this technology we can help an individual revive the relevant memories from the past that can change the present:  ameliorate symptoms and perhaps even change the future. 

The Mnemosymes of Jupiter have nothing on us.

Consult Your Inner Wisdom: It Has All the Answers

This past year, or two, in my clinical work, I experimented with a therapeutic technique that I cribbed from clinician/writer Sarah Krakauer. I found it useful both for my clients and for myself. I share it with you.

The assumption behind this idea is simple: at bottom, no matter how fractured our identity, or sense of self, there is within us a wholeness and a wisdom that we can consult as a sort of inner gyroscope. The theory goes that there is a unity within, and if we can gain access we can find a treasure trove of wise guidance.

I have worked with individuals who were highly “fractured” due to  severe trauma histories, as well as more intact individuals. The technique worked well with all kinds of people but I found that individuals with these fractures had an easier time accessing the “inner wisdom.”

The technique involves a simple visualization. One woman with whom I was working is diagnosed with Dissociative Identity Disorder, formerly known as Multiple Personality Disorder. This means, simply, that her identity is complex and multiple: she has very distinct and separate identities within a seemingly stable “self.”

Each “part” of this individual has a discrete and often contradictory point of view on any matter you could imagine: what to buy in the supermarket, for instance, junk food or organic kale . Or on any particular day if I am perceived as benign or as a threat. So checking across parts as to what the inner wisdom might suggest on any given topic is relevant to our enterprise.

What surprised me was that when we went through the inner wisdom I got the same answer to the question of the day: no contradictions, no evasions.

With this particular client I was often uncertain as to how to go forward in any given session, which part to address, how much to push for the traumatic memories that were just outside of her awareness. They could either liberate her from painful symptoms and/or de-stabilize her. Actually I was almost always struggling with these choices.

The inner wisdom always directed me to the traumatic material: go for it, it seemed to say. Don’t pay so much attention to the complaining about the pain that this causes. And the inner wisdom was right. After a period of turmoil, which was always difficult to weather, my patient was more solidly grounded, more mature, and eventually more integrated.

Now this is not magic, if the client was in retreat, warding me off, defending herself from incursions, I might get nothing. But this was relatively rare.

I describe the technique belo. Do try this at home.  Its perfectly safe.  Its probably more effective to have someone read this to you,   or record it yourself so you can hear the suggestions, not just imagine them.
Sit in a quiet place, close your eyes and visualize a corridor. This is a safe place. Off the corridor are doors. The door on the left is labeled “Hall of Inner Wisdom.” Open the door into a room that resembles a small movie theatre. The seats are comfortable. Sit down and see that at your finger tips is a keyboard. Type in the question that we are working on today: why does my hip hurt so much today, or what should I do about a troublesome relationship, should I change doctors, etc. Look up at the screen in front of you and there will be an answer.

Here you may see pictures or writing. You may just get thoughts popping up. If nothing comes, just sit quietly for awhile and see what happens.

I have tried this myself, going through the same steps of visualization. It feels a little like meditation, but with a very specific goal. Sometimes I get an answer. Not as frequently as my patient, alas. Often the answer surprises me. That’s what makes me think that this really is coming from a source quite different than my logical, linear, and deliberative mind.

What I think is going on here is that with the right tools and probably a bit of practice, one can have access to a part of the mind that is less rigid, less defensive, more intuitive, and more astute than the reasoning mind. I find it exciting and re-assuring that there is a guidance within with which I can make contact.